You’re Not Alone: Sharing of Anonymous Narratives to Destigmatize Mental Illness in Medical Students and Faculty

Medical students have a higher incidence of mental health problems than the general population (1). This trend is similar among physicians and residents (2, 3). Barriers to treatment-seeking include stigma-related concerns, including peer judgment (4).

Despite increasing efforts to destigmatize mental illness, negative attitudes towards mental health and help-seeking remain. One study found that students who experienced burnout were twice as likely to have seen a supervisor negatively judge a student who sought care (5). Another study found increased stigma around medical students disclosing depression to friends and increased stigma around working with depressed classmates (6). Medical students show even stronger stigma surrounding suicide, despite the alarming amount of medical student and physician suicides (7). Finally, students’ negative attitudes towards mental health translates into patient care, with medical students having low regard for patients with mental health complaints (8).

Steps can be taken to destigmatize mental illness. For example, a three-week group intervention called Coming Out Proud discussed topics such as when and how to disclose mental illness; it was shown to have positive effects on stigma and disclosure-related distress compared to treatment as usual in a randomized controlled study (9); a longitudinal undergraduate empowerment group showed similar results at Indiana University (10). Sharing personal stories in medical school can bring about a circle of trust, a sense of community, and increased awareness. This in turn can lead to decreased stigmatization of patients and, hopefully, improved outcomes for both patients and providers (8).

To this end, a group of medical school students at a public, east coast university hospital organized an event called You’re Not Alone: Talking about Mental Health in Medicine (YNA). Inspired by the It Happens Here Project (11) as well as the National Alliance on Mental Illness’ web page for personal stories (12), YNA aspired to provide a safe platform for students, staff, and faculty at this hospital to share their experiences with mental health and illness without fear of recognition or personal stigmatization. The event included readings of submitted stories by both medical trainees and practitioners, some of which were read anonymously, and some by the author. This was followed with a dinner and discussion and was closed with a brief exposition by one of the university’s mental health workers about available resources, including counseling and psychological services and our hospital’s psychiatric emergency program.

The Event

Medical students and faculty were invited to submit stories anonymously via a standardized form. They had the option of sharing their name and reading their own stories. After this, volunteer readers were assigned to share stories. Submitted entries included both personal and family anecdotes spanning topics such as depression, imposter syndrome, anxiety, obsessive compulsive disorder, anorexia nervosa, bipolar disorder, and suicide. Stories varied in length and form—some were as short as three lines while some were several pages long. Most were prose, though poetry was submitted as well.

YNA took place in a medical school auditorium. Around 60 people attended, including medical students and faculty as well as students and faculty from other schools such as nursing. Audience members were asked not to applaud at the end of each story, but rather to reflect on their own personal responses to each. Volunteers read their assigned stories in order, with a brief pause in silence between readings.

Excerpts from You’re Not Alone

Below are excerpts from the 18 stories that were read that evening. Note that, due to the submission form being anonymous, only people who volunteered to read their own stories were asked to share their stories here; the stories below, all from medical students, are transcribed with express permission for publication by the author of the respective story.

Excerpt 1: Year Three Medical Student

…It wasn’t until my first year of college that I had my first major depressive episode…I began to have intrusive images of hurting myself...It scared me enough that I went to the psychiatrist on campus and asked to be put on medication…[which] made me tired enough that I didn’t care as much, and that was enough for the time being. Throughout the rest of the year I remained on the medication. But then, [the following year]…I ran out of medication, and I told myself I would refill it later. But then I didn’t. And to my surprise, I was okay…It really hit me that I was no longer depressed when I was walking home from class—the sun was shining, the campus was beautiful, and I thought to myself “I love life.” And I realized I had never had that explicit thought before…

… Prior to [my third year of medical school] I had found a way to deal with my insecurity…I would be a jack of all trades, and if I wasn’t particularly good at any one thing I could rationalize that I couldn’t be since I was involved in so many activities. But during [third year] that wasn’t an option—there was no time. So I began to compare myself to other people again, and in my mind I was always inferior. I soon found myself in a depression once again. I couldn’t go to the school for therapy, since anytime that they might have offered services I was busy with medical duties. Fortunately, my previous social worker had evening hours, so I resumed therapy with him.

I realize now that my depression is never going to go away. Even though I am generally a very happy person, there will be periods in my life when the depression will return. My attitude now is that I will be prepared for it…regardless of where I end up [for residency], I will make sure that I find a therapist right away, even just to establish a baseline. I’m also continuing mindfulness meditation. My hope is that the next time my depression strikes, I will be able to keep it under control so that it doesn’t affect my functioning.

Excerpt 2: Year Three Medical Student

Throughout my years of trying to get better, one phrase has stuck in my mind. I saw it about 10 years ago on a NYC subway, one of the Poetry in Motion poems. I don’t remember the exact words, but I do remember the general idea. “Mood is like a string of colored beads.” I remember thinking to myself that I needed to move on to the next bead, the only problem was I didn’t know how. I was stuck, trapped in maybe a dark purple or actually, probably just an ugly grey.

I was stuck in many ways. I still am, although to a much lesser extent. There are things I hold on to, things I have hard time letting go of. There is loss; that is probably the most difficult thing to move on from. But I can say that with help, I have successfully moved on to other, brighter beads. I know this is cheesy, but I’ve been telling myself for 10 years now that there is always another bead, I just have to get there.

Excerpt 3: Year Two Medical Student

Nobody ever saw or acknowledged how sick I was until about 5 years ago. I started passing out…Each time I made up lies about being dehydrated or too hot. I ended up in the hospital with a hemoglobin of 6.4 and an iron of 2, which would be attributed to undiagnosed celiac disease…I counted calories obsessively and had little papers stuffed everywhere with counts, but I hid them around my home. My doctors always commented on my weight, but I would convince them I was just very health conscious…I was a member of [an athletic] club…where it was not only the norm, but expected that we exercise daily and excessively…I developed a crack in the neck of my femur, but was so accustomed to ignoring pain that I [performed a] triathlon on it. I couldn’t walk for the next 6 months and my doctor pressed me about my eating. I lied to him regularly and said I had bone density studies that were normal.

I eventually sought mental health care when I was suicidal. My therapist told me that I had anorexia nervosa and I began treatment…my therapist then suggested prolonged exposure treatment for PTSD…I completely did not understand why treatment for PTSD would help me — I wasn’t a war vet and I was never abused. Nonetheless, I completed the 10-week exposure therapy that focused on the loss of [a family member]. I had to relive this trauma every day and force myself to acknowledge and face the things I had learned to avoid…

…Although losing my [family member] was devastating, traumatic, and life-altering, I have come to a place in my life where I appreciate all the things I gained from this experience. I have since found out that [they] used cocaine regularly and [their] death was likely attributable to this. This…is the major reason I have become so passionate about treating addictions. My ongoing treatment and lifelong struggle with anorexia has left me a more empathetic and compassionate person and hopefully, eventually, an incredible physician.

Reactions by the audience and volunteers

Medical students who attended the event described it as “heavier than expected.” They were impressed by the courage of the authors and readers in sharing very personal stories, and some expressed interest in sharing their own next year. Faculty who attended the event stated that it was “quite powerful and of value” and they wished more faculty attended. Suggestions for improvement included a more intimate location and including time where audience members could share their own stories if they desired.

Below are reflections from medical student organizers of the event.

Reflection 1

An anonymous student came up to me and felt relieved that their story was expressed without having to come forward. They stated that by having all these stories read together, they found peace in knowing that they are not alone in fighting depression throughout medical school.

Reflection 2

I recall hearing one of my peers, who is also a friend, tell her story of growing up and her journey to medical school. She chose to not remain anonymous...I had never known the challenges she faced…To know that my friend persevered through all that had made me so proud to know her and also made me view my own challenges as a bit less daunting.

Reflection 3

I was interested in the attendance at the event: a significant amount of students, accompanied by attendings. However, there were almost no residents, which seems to highlight an issue in this kind of event…some of the people who are likely struggling the most were unable/unwilling to come, even though their stories would have illustrated the third ground between medical student and attending. Perhaps it is an indictment of the medical training pathway that residents are not able to engage in such activities.

Discussion

Mental illness, if untreated, can lead to devastating outcomes. Sadly, help seeking behavior is significantly impacted by stigmatizing attitudes—a review of 27 studies showed that negative attitudes towards mental health are associated with less help seeking (13). Moreover, a review of 144 studies found that disclosure related concerns comprised the most common stigma barrier to help-seeking (14). The combination of mental illness and stigma in the medical community likely plays a large role in the prevalence of student and physician burnout (15, 16). YNA was an attempt to reduce disclosure-related stigma by allowing people to discuss their experiences anonymously. By reducing this stigma, our hope is that 1) students and faculty will feel less isolated and more willing to seek treatment, and 2) students and faculty not suffering from mental illness will be more educated in the real-life prevalence and impact of such illness in colleagues and patients, and thus more supportive of them in their time of need.

To our knowledge, an event such as YNA that is candid yet anonymous about mental illness has not been organized at another hospital previously. While we can qualitatively conclude this event was beneficial based on verbal feedback, the scope of this event was limited. In order to determine longitudinal impact on stigma and help-seeking behavior, surveys such as the Social Distance Scale for mental illness (SDS) (17) and the Mental Help Seeking Attitudes Scale (MHSAS) (18) can be administered yearly before and after the event. Other institutions may hold similar events and report on event outcomes.

We intend to make this a yearly event at our institution. In addition, we plan to actively reach out to and include residents in planning the event, which will hopefully increase the number of residents that attend. We also hope to obtain quantitative data as to the event’s usefulness through measures such as the MHSAS and SDS, as mentioned above. Finally, we aim to track attendance and participation to evaluate the level of impact over time. For context, our institution has around 130 medical students per year and well over 100 faculty members—with increased publicity and involvement in planning, the number of attendees and participants will hopefully increase.

As medical schools strive to address mental illness, personal stigma remains a significant impediment. Perhaps events such as YNA can be a first step in students and faculty opening up about their struggles so that they can seek further help from others. Creating a culture of help-seeking and affirmation with mental health and illness can help refocus the ethos of the medical field to encourage better self-care and de-stigmatization, for the benefit of both practitioners and patients.